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Guide to Nursing ResourcesGuide to Nursing ResourcesEBN : Accessing the ResearchEBN : Accessing the Research
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Learning ObjectivesLearning Objectives
Introduce student to evidence-Introduce student to evidence-based nursing literature andbased nursing literature and
effective strategies for searchingeffective strategies for searching
for and accessing evidence-for and accessing evidence-
based research in nursing.based research in nursing.
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06/18/09 IUON - Library Research 3
What is EBM?What is EBM?
Evidence based medicine is theEvidence based medicine is theconscientious, explicit, and judiciousconscientious, explicit, and judicioususe of current best evidence inuse of current best evidence in
making decisions about the care ofmaking decisions about the care ofindividual patients. The practice ofindividual patients. The practice ofevidence based medicine meansevidence based medicine meansintegrating individual clinicalintegrating individual clinicalexpertise with the best availableexpertise with the best availableexternal clinical evidence fromexternal clinical evidence fromsystematic research.systematic research.
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB,Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB,
Richardson WS.Richardson WS.Evidence based medicine: what it is and what it isn'tEvidence based medicine: what it is and what it isn't..
http://bmj.com/cgi/content/full/312/7023/71?view=full&pmid=8555924http://bmj.com/cgi/content/full/312/7023/71?view=full&pmid=8555924http://bmj.com/cgi/content/full/312/7023/71?view=full&pmid=85559248/14/2019 Nursing Research Resources 72
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Evidence Based MedicineEvidence Based Medicine
EBM Decision Model:EBM Decision Model:
"Evidence-based medicine (EBM) is"Evidence-based medicine (EBM) is
the integration of best researchthe integration of best researchevidence with clinical expertiseevidence with clinical expertise
and patient values."and patient values."
EBM Cycle:EBM Cycle:
Ask, Acquire, Appraise, Apply andAsk, Acquire, Appraise, Apply and
ActAct
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Primary EvidencePrimary Evidence
Primary evidence includes thePrimary evidence includes the
original reportsoriginal reports of researchof researchstudies and are included instudies and are included in
journal citation databases:journal citation databases: MEDLINE: randomized controlledMEDLINE: randomized controlled
trialstrials
CINAHL: researchCINAHL: research
EMBASEEMBASE
SCIRUSSCIRUS
http://www.embase.com/http://www.embase.com/http://www.scirus.com/http://www.scirus.com/http://www.scirus.com/http://www.embase.com/8/14/2019 Nursing Research Resources 72
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Secondary EvidenceSecondary Evidence
Secondary evidence is theSecondary evidence is the analysisanalysisof research studies and is foundof research studies and is found
in:in: MEDLINE: meta-analysis, practiceMEDLINE: meta-analysis, practice
guidelines, consensus developmentguidelines, consensus development
conferencesconferences
CINAHL: meta-analysis, practice guidelines,CINAHL: meta-analysis, practice guidelines,
research based nursing practiceresearch based nursing practice
Cochrane Database of Systematic ReviewsCochrane Database of Systematic Reviews
Database of Reviews of EffectivenessDatabase of Reviews of Effectiveness
(DARE)(DARE)
National Guidelines Clearin houseNational Guidelines Clearinghouse
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Information PyramidInformation Pyramid
06/18/09 IUON - Library Research 7
EBM journals
Cochrane DBSystemic reviews
Clinical Practice
Guidelines
primary research articles
CINAHL, Medline
Assoc. websites,textbooks
Adapted from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12113514http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=121135148/14/2019 Nursing Research Resources 72
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Evolution of LiteratureEvolution of Literature
Evidence PyramidEvidence PyramidThe base of the pyramid is whereThe base of the pyramid is where
information usually starts with an ideainformation usually starts with an idea
or laboratory research. As these ideasor laboratory research. As these ideas
turn into drugs and diagnostic toolsturn into drugs and diagnostic tools
they are tested in laboratories models,they are tested in laboratories models,then in animals, and finally in humans.then in animals, and finally in humans.
The human testing may begin withThe human testing may begin with
volunteers and go through severalvolunteers and go through several
phases of clinical trials before the drugphases of clinical trials before the drug
or diagnostic tool can be authorizedor diagnostic tool can be authorized
for use within the general population.for use within the general population.
Randomized controlled trials are thenRandomized controlled trials are then
done to further test the effectivenessdone to further test the effectivenessand efficacy of a drug or therapy.and efficacy of a drug or therapy.
As you move up the pyramid theAs you move up the pyramid the
amount of available literatureamount of available literature
decreases, but increases in itsdecreases, but increases in its
relevance to the clinical setting.relevance to the clinical setting.
Type of StudyType of Study Meta-Meta-
AnalysisAnalysis
SystematicSystematic
ReviewReview
RandomizedRandomized
Controlled TrialControlled Trial
Cohort studiesCohort studies
Case Control studiesCase Control studies Case Series/Case ReportsCase Series/Case Reports
AnimalAnimal
research/Laboratoryresearch/Laboratory
studiesstudies
http://www.hsl.unc.edu/services/tutorials/EBM/Supplements/QuestionSupplement.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/Supplements/QuestionSupplement.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/Supplements/QuestionSupplement.htm8/14/2019 Nursing Research Resources 72
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Medical DatabasesMedical Databases
CINAHLCINAHL EBSCOEBSCOhosthost
http://http://
support.epnet.com/trsupport.epnet.com/tr
CINAHL.comCINAHL.com Online trainingOnline training
http://http://www.cinahl.com/liwww.cinahl.com/li
MedlineMedline EBSCOEBSCOhosthost
PubMedPubMed Online trainingOnline training
http://http://
www.nlm.nih.gov/www.nlm.nih.gov/
http://support.epnet.com/training/tutorials.phphttp://support.epnet.com/training/tutorials.phphttp://support.epnet.com/training/tutorials.phphttp://support.epnet.com/training/tutorials.phphttp://www.cinahl.com/library/library.htmhttp://www.cinahl.com/library/library.htmhttp://www.cinahl.com/library/library.htmhttp://www.cinahl.com/library/library.htmhttp://www.nlm.nih.gov/bsd/disted/pubmed.htmlhttp://www.nlm.nih.gov/bsd/disted/pubmed.htmlhttp://www.nlm.nih.gov/bsd/disted/pubmed.htmlhttp://www.nlm.nih.gov/bsd/disted/pubmed.htmlhttp://www.nlm.nih.gov/bsd/disted/pubmed.htmlhttp://www.nlm.nih.gov/bsd/disted/pubmed.htmlhttp://www.cinahl.com/library/library.htmhttp://www.cinahl.com/library/library.htmhttp://support.epnet.com/training/tutorials.phphttp://support.epnet.com/training/tutorials.php8/14/2019 Nursing Research Resources 72
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Evidence in MEDLINEEvidence in MEDLINE
Searching for evidence in MEDLINESearching for evidence in MEDLINE
includes several steps:includes several steps:
formulate a clinical questionformulate a clinical question run a subject searchrun a subject search
Ex. heart disease and aspirinEx. heart disease and aspirin
select a strategy to retrieveselect a strategy to retrieveliterature related toliterature related to therapy,therapy,diagnosis, prognosis,diagnosis, prognosis,
harm/etiology.harm/etiology.
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Evidence in CINAHLEvidence in CINAHL
formulate a clinicalformulate a clinical
questionquestion
run a subjectrun a subject
searchsearch use the Researchuse the Research
limit on the Mainlimit on the Main
Search Page.Search Page. This is a very effective way toThis is a very effective way to
limit retrieval to researchlimit retrieval to research
studies in CINAHL.studies in CINAHL.
Tutorial:Tutorial: http://http://www.hscl.ufl.edu/help/CINAwww.hscl.ufl.edu/help/CINA
http://www.hscl.ufl.edu/help/CINAHL/index.htmhttp://www.hscl.ufl.edu/help/CINAHL/index.htmhttp://www.hscl.ufl.edu/help/CINAHL/index.htmhttp://www.hscl.ufl.edu/help/CINAHL/index.htm8/14/2019 Nursing Research Resources 72
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Cochrane Database of SystemicCochrane Database of Systemic
ReviewsReviews
includes the full text of theincludes the full text of theregularly updatedregularly updated
systematic reviews of thesystematic reviews of the
effects of healthcareeffects of healthcare
prepared by The Cochraneprepared by The Cochrane
CollaborationCollaboration can be searched bycan be searched by
combing keywords orcombing keywords or
phrases.phrases.
TheThe Browse TopicsBrowse Topics iconicon
retrieves a list of Cochraneretrieves a list of CochraneGroups who prepare andGroups who prepare and
maintain the reviews inmaintain the reviews in
respective clinical areas,respective clinical areas,
such as nursing.such as nursing.
http://http://www.cochrane.org/index.htmwww.cochrane.org/index.htm
http://www.cochrane.org/index.htmhttp://www.cochrane.org/index.htmhttp://www.cochrane.org/index.htmhttp://www.cochrane.org/index.htmhttp://www.cochrane.org/index.htmhttp://www.cochrane.org/index.htm8/14/2019 Nursing Research Resources 72
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Database of Reviews of Effectiveness (DAREDatabase of Reviews of Effectiveness (DARE
Database of Reviews of Effectiveness (DARE) a full textDatabase of Reviews of Effectiveness (DARE) a full text
database with critical structured abstracts of studiesdatabase with critical structured abstracts of studies
reported in various medical journals.reported in various medical journals.
http://www.york.ac.uk/inst/crd/crddatabases.htmhttp://www.york.ac.uk/inst/crd/crddatabases.htmhttp://www.york.ac.uk/inst/crd/crddatabases.htm8/14/2019 Nursing Research Resources 72
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What is SystemicWhat is Systemic
Review?Review?
Systematic reviews are known as theSystematic reviews are known as the
highest level of evidence in clinicalhighest level of evidence in clinical
research.research.
Developed countries are developing theirDeveloped countries are developing theirmedical guidelines based on the informationmedical guidelines based on the information
provided by systematic reviews ofprovided by systematic reviews of
effectiveness.effectiveness.
Therefore, it is mandatory for allTherefore, it is mandatory for all
professionals involved in the delivery ofprofessionals involved in the delivery of
healthcare, to reach to a goodhealthcare, to reach to a good
understanding about systematic reviews.understanding about systematic reviews.
This web site offers information about whatThis web site offers information about what
systematic reviews are, and how to conductsystematic reviews are, and how to conduct
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TheThe
National Guidelines ClearinghouseNational Guidelines Clearinghouse
includes evidence-based practice guidelines from variousincludes evidence-based practice guidelines from various
health centers and organizations. It can be searched byhealth centers and organizations. It can be searched by
disease, treatment or organization. The Clearinghousedisease, treatment or organization. The Clearinghouse
includes a feature comparing attributes of two or moreincludes a feature comparing attributes of two or more
guidelines.guidelines.
http://www.guidelines.gov/http://www.guidelines.gov/http://www.guidelines.gov/8/14/2019 Nursing Research Resources 72
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HealthWebHealthWeb
TheThe Evidence-Based Health CareEvidence-Based Health Care
section of HealthWeb includes asection of HealthWeb includes awealth of information about EBwealth of information about EB
organizations, databases andorganizations, databases and
publications.publications.
The Tools and Tutorials has manyThe Tools and Tutorials has many
helpful links including thehelpful links including the
EBM Tool KitEBM Tool Kit andand EBM ToolboxEBM Toolbox..
http://www.healthweb.org/http://www.healthweb.org/http://healthweb.org/browse.cfm?subjectid=39http://healthweb.org/browse.cfm?subjectid=39http://www.med.ualberta.ca/ebm/ebm.htmhttp://www.med.ualberta.ca/ebm/ebm.htmhttp://www.cebm.net/toolbox.asphttp://www.cebm.net/toolbox.asphttp://www.cebm.net/toolbox.asphttp://www.med.ualberta.ca/ebm/ebm.htmhttp://healthweb.org/browse.cfm?subjectid=39http://www.healthweb.org/8/14/2019 Nursing Research Resources 72
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OtherOther
Search EnginesSearch Engines
MedstoryMedstory
Google ScholarGoogle Scholar
MammaHealthMammaHealth MedlinePlusMedlinePlus
KosmixKosmix
ReleMedReleMed
DatabasesDatabases
DynaMedDynaMed
Up-to-DateUp-to-Date
MDConsultMDConsult NursingConsultNursingConsult
InfoPOEMSInfoPOEMS
St t i Cli i lSt t i Cli i l
http://www.medstory.com/http://www.medstory.com/http://scholar.google.com/http://scholar.google.com/http://www.mammahealth.com/http://www.mammahealth.com/http://www.medlineplus.com/http://www.medlineplus.com/http://www.kosmix.com/http://www.kosmix.com/http://www.relemed.com/http://www.relemed.com/http://www.uptodate.com/http://www.uptodate.com/http://eresourcesonline.com/resources/default.asp?what=MDCONSULThttp://eresourcesonline.com/resources/default.asp?what=MDCONSULThttp://eresourcesonline.com/resources/default.asp?what=NURSINGCONSULThttp://eresourcesonline.com/resources/default.asp?what=NURSINGCONSULThttp://www.infopoems.com/http://www.infopoems.com/http://www.infopoems.com/http://eresourcesonline.com/resources/default.asp?what=NURSINGCONSULThttp://eresourcesonline.com/resources/default.asp?what=MDCONSULThttp://www.uptodate.com/http://www.relemed.com/http://www.kosmix.com/http://www.medlineplus.com/http://www.mammahealth.com/http://scholar.google.com/http://www.medstory.com/8/14/2019 Nursing Research Resources 72
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Steps to answering ClinicalSteps to answering Clinical
Questions using the MedicalQuestions using the Medical
LiteratureLiterature
The Anatomy of the ClinicalThe Anatomy of the Clinical
Question:Question:
1. Formulate a clinical question1. Formulate a clinical question("PICO" approach):("PICO" approach):
PPatient characteristicsatient characteristics
IIntervention being consideredntervention being consideredCComparison intervention (if any)omparison intervention (if any)
OOutcome of clinical interestutcome of clinical interest
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Clinical Question cont.Clinical Question cont.
2. Run your subject search.2. Run your subject search.
3. Select the MEDLINE strategy to3. Select the MEDLINE strategy to
answer the question:answer the question:
Therapy, Diagnosis, Prognosis,Therapy, Diagnosis, Prognosis,Harm/Etiology.Harm/Etiology.
(including study design/article(including study design/article
type)type)
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For Quick SearchesFor Quick Searches
A question of...A question of...
TherapyTherapyLimit search to PublicationLimit search to Publication
Type -Type - Randomized ControlledRandomized Controlled
TrialTrial ptpt
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In-depth EBM Searches:In-depth EBM Searches:
TherapyTherapy
exp research design/ or exp clinical trials/ orexp research design/ or exp clinical trials/ or
comparative study/ or placebos/ orcomparative study/ or placebos/ or
multicenter study.pt. or clinical trial$1.pt. Ormulticenter study.pt. or clinical trial$1.pt. Or
random$.ti,ab. or (single blind$ or doublerandom$.ti,ab. or (single blind$ or double
blind$ or triple blind$3).ti,ab. orblind$ or triple blind$3).ti,ab. or
placebo$1.ti,ab. or (clinical adjtrial$1).ti,ab.placebo$1.ti,ab. or (clinical adjtrial$1).ti,ab.
or exp epidemiologic research design/ oror exp epidemiologic research design/ or(controlled clinical trial or randomized(controlled clinical trial or randomized
controlled trial).pt. or practice guideline.pt.controlled trial).pt. or practice guideline.pt.
Or feasibility studies/ or clinical protocols/ orOr feasibility studies/ or clinical protocols/ or
exp treatment outcome/ or double blindexp treatment outcome/ or double blind
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For Quick SearchesFor Quick Searches
A question of...A question of...
DiagnosisDiagnosisCombine subject search withCombine subject search with
search forsearch for exp "sensitivity andexp "sensitivity and
specificity"specificity"
I d h EBM S h
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In-depth EBM Searches:In-depth EBM Searches:
DiagnosisDiagnosis
exp "sensitivity and specificity"/ or falseexp "sensitivity and specificity"/ or false
negative reactions/ or false positivenegative reactions/ or false positive
reactions/ or (sensitivity or specificity).ti,ab.reactions/ or (sensitivity or specificity).ti,ab.
or (predictive adj value$1).ti,ab. oror (predictive adj value$1).ti,ab. or
(likelihood adj ratio$1).ti,ab. or (false adj(likelihood adj ratio$1).ti,ab. or (false adj
(negative$1 or positive$1)).ti,ab. or(negative$1 or positive$1)).ti,ab. or
(randomized controlled trial or controlled(randomized controlled trial or controlled
clinical trial).pt. or double blind method/ orclinical trial).pt. or double blind method/ or
single blind method/ or practicesingle blind method/ or practiceguideline.pt. Or consensus developmentguideline.pt. Or consensus development
conference$.pt. or random$.ti,ab. or randomconference$.pt. or random$.ti,ab. or random
allocation/ or (single blind$3 or doubleallocation/ or (single blind$3 or double
blind$3 or triple blind$3).ti,ab.blind$3 or triple blind$3).ti,ab.
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For Quick SearchesFor Quick Searches
A question of...A question of...
PrognosisPrognosisCombine subject search withCombine subject search with
search forsearch for exp cohort studiesexp cohort studies
oror exp riskexp risk
d h S hI d th EBM S h
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In-depth EBM Searches:In-depth EBM Searches:
PrognosisPrognosis
exp cohort studies/ or prognosis/ or expexp cohort studies/ or prognosis/ or exp
mortality/ or exp morbidity/ ormortality/ or exp morbidity/ or
(natural adj history).ti,ab. or(natural adj history).ti,ab. or
prognos$.ti,ab. or course.ti,AB orprognos$.ti,ab. or course.ti,AB orpredict$.ti,ab. or exp "outcomepredict$.ti,ab. or exp "outcome
assessment (health care)"/ orassessment (health care)"/ or
outcome$1.ti,ab. or (inception adjoutcome$1.ti,ab. or (inception adj
cohort$1).ti,ab. or diseasecohort$1).ti,ab. or diseaseprogression/ or exp survival analysis/progression/ or exp survival analysis/
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For Quick SearchesFor Quick Searches
A question of...A question of...
Harm/EtiologyHarm/EtiologyCombine subject search withCombine subject search with
search forsearch for exp cohort studiesexp cohort studies
OR exp riskOR exp risk
I d th EBM S hI d th EBM S h
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In-depth EBM Searches:In-depth EBM Searches:
Harm/EtiologyHarm/Etiology
random$.ti,ab. or exp epidemiologicalrandom$.ti,ab. or exp epidemiological
studies/ or odds ratio/ orstudies/ or odds ratio/ or
cohort$.ti,ab. or (case$1 adjcohort$.ti,ab. or (case$1 adj
control$).ti,ab. or risk$.ti,ab. or (oddscontrol$).ti,ab. or risk$.ti,ab. or (oddsadj ratio$1).ti,ab. or causa$.ti,ab. oradj ratio$1).ti,ab. or causa$.ti,ab. or
(relative$1 adj risk$).ti,ab. or(relative$1 adj risk$).ti,ab. or
predispos$.ti,ab. or (randomizedpredispos$.ti,ab. or (randomized
controlled trial or controlled clinicalcontrolled trial or controlled clinicaltrial).pt. or exp risk/ or practicetrial).pt. or exp risk/ or practice
guideline.pt. or exp case-controlguideline.pt. or exp case-control
studies/ or exp cohort studies/studies/ or exp cohort studies/
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For Quick SearchesFor Quick Searches
4. Locate other sources of4. Locate other sources of
evidence as necessary.evidence as necessary.
5. Examine the evidence, critically5. Examine the evidence, criticallyappraise/evaluate the literature.appraise/evaluate the literature.
6. Apply the evidence + clinical6. Apply the evidence + clinical
experience + the patient'sexperience + the patient's
preferences.preferences.
7. Evaluate patient outcomes.7. Evaluate patient outcomes.
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In-depth EBM SearchesIn-depth EBM Searches
4. Once copied, paste it into the4. Once copied, paste it into the
search box in MEDLINE.search box in MEDLINE.
5. Click "5. Click "Perform SearchPerform Search."."6. Combine this set with your6. Combine this set with your
original search usingoriginal search using ANDAND (i.e. 1(i.e. 1
AND 2).AND 2).
(EBM filters developed by the Miner(EBM filters developed by the Miner
Library at theLibrary at the
University of Rochester Medical CenteUniversity of Rochester Medical Cente
http://www.urmc.rochester.edu/hslt/miner/index.cfmhttp://www.urmc.rochester.edu/hslt/miner/index.cfmhttp://www.urmc.rochester.edu/hslt/miner/index.cfm8/14/2019 Nursing Research Resources 72
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NoteNote
You can save each of these EBM filters as a separateYou can save each of these EBM filters as a separatesearch in MEDLINE so that they can be run assearch in MEDLINE so that they can be run as
needed when searching MEDLINEneeded when searching MEDLINE
To do this:To do this:
Authenticate to a new MEDLINE session with aAuthenticate to a new MEDLINE session with a
blank search history.blank search history.
Copy and paste one EBM filter.Copy and paste one EBM filter.
Click "Click "Perform SearchPerform Search."."
After retrieving search results, click "After retrieving search results, click "Save SearchSave Search
HistoryHistory."."
Select "Select "PermanentPermanent," and name the search (ex.," and name the search (ex.
EBM Therapy or Therapy Filter).EBM Therapy or Therapy Filter).
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To use save searches:To use save searches:
Run your subject search.Run your subject search.
Click "Click "Run Saved SearchRun Saved Search."."
Select the EBM filter to run basedSelect the EBM filter to run basedon the type of question beingon the type of question being
asked (Therapy, Diagnosis,asked (Therapy, Diagnosis,
Prognosis, or Harm/Etiology).Prognosis, or Harm/Etiology).
Combine the two searches usingCombine the two searches using
ANDAND..
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EVIDENCE BASEDEVIDENCE BASEDMEDICINE TOOLKITS &MEDICINE TOOLKITS &
TUTORIALSTUTORIALS
For further clarification and practice check out more onlineFor further clarification and practice check out more online
training EBM Toolkit based on the series in JAMA:training EBM Toolkit based on the series in JAMA:
http://http://www.med.ualberta.ca/ebm/ebm.htmwww.med.ualberta.ca/ebm/ebm.htm
ORORFrom Duke University Medical Center:From Duke University Medical Center:
http://http://
www.hsl.unc.edu/services/tutorials/EBM/welcome.htmwww.hsl.unc.edu/services/tutorials/EBM/welcome.htm
http://www.med.ualberta.ca/ebm/ebm.htmhttp://www.med.ualberta.ca/ebm/ebm.htmhttp://www.med.ualberta.ca/ebm/ebm.htmhttp://www.med.ualberta.ca/ebm/ebm.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/welcome.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/welcome.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/welcome.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/welcome.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/welcome.htmhttp://www.hsl.unc.edu/services/tutorials/EBM/welcome.htmhttp://www.med.ualberta.ca/ebm/ebm.htmhttp://www.med.ualberta.ca/ebm/ebm.htm8/14/2019 Nursing Research Resources 72
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EBM JeopardyEBM Jeopardy
http://www.mclibrary.duke.edu/training/courses/ebmworkshop/ebmjeopardy.ppthttp://www.mclibrary.duke.edu/training/courses/ebmworkshop/ebmjeopardy.ppthttp://www.mclibrary.duke.edu/training/courses/ebmworkshop/ebmjeopardy.ppt8/14/2019 Nursing Research Resources 72
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Thank youThank youAnn Celestine,Ann Celestine, BA MLS AHIPBA MLS AHIP
Library DirectorLibrary Director